Guidelines for the management of male urinary tract infections in primary care: a lack of international consensus—a systematic review of the literature

Abstract

Background

The management of adult male urinary tract infections (mUTIs) in primary care lacks international consensus. The main objective of this study was to describe the different guidelines for the diagnosis and management of mUTIs in primary care, to assess their methodological quality, and to describe their evidence-based strength of recommendation (SoR).

Methods

An international systematic literature review of the electronic databases Medline (PubMed) and EMBASE, and gray-literature guideline-focused databases was performed in 2021. The Appraisal of Guidelines for Research and Evaluation (AGREE II) assessment tool was used by 2 independent reviewers to appraise each guideline.

Results

From 1,678 records identified, 1,558 were screened, 134 assessed for eligibility, and 29 updated guidelines met the inclusion criteria (13 from Medline, 0 from EMBASE, and 16 from gray literature). Quality assessment revealed 14 (48%) guidelines with high-quality methodology. A grading system methodology was used in 18 (62%) guidelines. Different classifications of mUTIs are described, underlining a lack of international consensus: an anatomic classification (cystitis, prostatitis, pyelonephritis) and a symptomatic classification (approach based on the intensity and tolerance of symptoms). The duration of antibiotic treatment for febrile mUTIs has been gradually reduced over the last 20 years from 28 days to 10–14 days of fluoroquinolones (FQ), which has become the international gold standard. Guidelines from Scandinavian countries propose short courses (3–5 days) of FQ-sparing treatments: pivmecillinam, nitrofurantoin, or trimethoprim. Guidelines from French-speaking countries use a watchful waiting approach and suggest treating mUTIs with FQ, regardless of fever.

Conclusions

This lack of scientific evidence leads to consensus and disagreement: 14 days of FQ for febrile mUTIs is accepted despite a high risk of antimicrobial resistance, but FQ-sparing treatment and/or short treatment for afebrile mUTIs is not. The definition of afebrile UTIs/cystitis is debated and influences the type and duration of antibiotic treatment recommended.

Background

The incidence of adult male urinary tract infections (mUTIs) is poorly known and varies by country and definition (1–3). The variability of international nomenclatures induces classification biases (4). In a Dutch primary care database, the incidence of mUTIs was 18.4 per 1,000 person-years at risk (‰ PY). In terms of the ICPC-2 (International Classification of Primary Care) classification, cystitis is the most common UTI (10‰ PY), followed by prostatitis (2‰ PY) and pyelonephritis (1‰ PY) (1). The incidence of mUTIs increases with age (5). In a Norwegian primary care database, male patients accounted for 14.7% of consultations for cystitis and 23.2% of consultations for pyelonephritis (6). Male UTIs are rare in French general practice with fewer than 2 cases per physician per year (7). In an Irish qualitative study, general practitioners (GPs) consider mUTIs as rare and polymorphic events and diagnosis and treatment as complex (8). GPs often treat all mUTIs as complicated UTIs, which usually involves the use of second-line antimicrobial agents like fluoroquinolones (FQ), or longer courses (8).

Escherichia coli is the most frequently isolated strain (48%–82%) followed by other enterobacteriaceae and enterococci (9). The prevalence of Pseudomonas æruginosa increases with age and health care-associated infections (10). There is a north-to-south and west-to-east gradient of resistance to FQ in E. coli, with higher rates observed in the southern and eastern parts of Europe (11,12). Escherichia coli isolates resistant to FQ have increased over 15 years: Sweden (2005: 4.7%, 2020: 14.1%), Italy (28.2%, 37.6%), and France (11%, 15.9%) (11,12). In Asia, FQ resistance to E. coli exceeds 50% (13). FQ are classified in the “Watch group” by the WHO-Essential List Medicines (WHO-EML), including antibiotic classes that are considered to have higher toxicity concerns or resistance potential (14,15). Furthermore, a meta-analysis of 5 studies of UTIs managed in primary care found an increased risk of antibiotic resistance that persisted for up to 1 year and a higher risk associated with multiple courses of antibiotics (16).

Guidelines are essential tools to promote antimicrobial stewardship (AMS) and to monitor local antibiotic resistance among primary care professionals (17). AMS must be adapted to local epidemiology and resistance patterns in different regions and must inform the rigorous assessment of the evidence and in collaboration with professional societies (17).

There are only a few randomized controlled trials on the management of mUTIs in primary care and these studies use heterogeneous definitions to define mUTIs (18–21). Therapeutic guidelines still differ greatly from one country to another. In France, the gold standard is 14 days of treatment with FQ for afebrile mUTIs (22). However, the United Kingdom recommends 7 days of treatment with nitrofurantoin for male cystitis (23). To our knowledge, there is no systematic literature review of the quality and content of national guidelines for the management of mUTIs.

The main objective of this study was to describe the different guidelines for the diagnosis and management of mUTIs in primary care, to assess their methodological quality and to describe their evidence-based strength of recommendation (SoR).

Material and Methods

Data source and search strategy

We conducted a systematic literature review from November 2020 to October 2021, using PRISMA criteria (24). We have limited the inclusion of records after 1990.

Data sources

The Medline database (PubMed) and EMBASE were used to identify relevant published references in November 2020. The search terms are reported in Table 1.

We also analyzed a selection of institutional medical websites, including health institutes, health agencies, and guideline websites. A snowball manual search for references of published originals studies of male UTI was conducted to find guidelines websites (Table 2). The keywords “cystitis,” “prostatitis,” and “pyelonephritis” in English or French were entered into the search boxes of each site in February 2021. For non-English-speaking websites, we used the translation software DeepL (version 3.2) to translate guidelines; this software has proven to be accurate in medical translation (25).

Eligibility criteria and selection processes

Clinical practice guidelines and guidance documents with recommendations for the diagnosis or management of mUTIs that were produced by regional, national, or international clinical institutions were eligible for inclusion. Guidelines describing UTIs (male and female) regardless of level of care were initially included. We secondarily included guidelines that cover mUTI management in primary care.

References regarding the management of chronic UTIs requiring specialist urology input, female UTIs only, pediatric, or urological specialties were not included.

Original studies, opinion letters, abstracts, or commentaries were not included.

The list of references identified in the database was established, and duplicate entries were eliminated. If multiple national/regional guidelines were found, they were all included to describe their change over time. Then, the guideline considered to be the most up-to-date (i.e. updated guidelines) was included to assess its methodological quality.

Each reference was analyzed for inclusion by 2 independent investigators (B.S. and F.R.). Disagreements were resolved by consensus.

Data extraction

The following data were extracted and recorded in a dedicated Microsoft Excel spreadsheet: date of guideline, country, medical specialty of author, UTI nosology, antibiotics (type, duration, and dosage), and other treatment, further investigations, and search for features accompanying mUTIs.

Quality assessment

The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used independently (B.S. and F.R.) to determine the quality of each national guideline (26,27). The 6 domains assessed were scope and purpose, stakeholder involvement, rigor of development including evidence base, clarity of presentation, applicability, and editorial independence. Domains were scored on a 1- to 7-point scale (Supplementary Material); any score that varied by >3 of 7 was discussed and revised if this was felt to be reasonable. In accordance with AGREE II instructions, the overall quality of each domain was calculated as a percentage (27). We report median and interquartile range (IQR) per domain across guidelines (Table 3). As suggested by Kirolos et al., guidelines with a score above a threshold of 60% were considered to have a high quality of methodology (28).

Level of evidence and strength of recommendation

National/regional scales for grading levels of evidence (LoE) and strength of recommendation (SoR) were converted to GRADE (Grading of Recommendation, Assessment, Development and Evaluations) LoE and SoR. Due to heterogeneity between grading systems, we converted SoR into 3 categories: high, moderate and low grade indicated by shading of results in Table 4. For better understanding, we used our scores for AGREE II items 11, 9, and 12, for respectively, whether benefits and risks were considered, whether strengths and limitations of evidence were described, and whether evidence was linked to a SoR (Table 5). We based our methodology on the work of Suzuki et al. (29).

Results

Among the 1,678 identified references, 36 guidelines met the inclusion criteria corresponding to 29 updated guidelines. Seven of the 36 guidelines had been updated during the inclusion period (Table 6). Finally, among the 29 updated guidelines, 13 were retrieved from Medline, 0 from Embase, and 16 from the gray literature (12 were from institutes, health agencies, and guidance websites and 4 guidelines from African countries were from the WHO database). Ten guidelines were written neither in English nor French (Table 6). PRISMA 2020 flow diagram is shown in Figure 1.

Included guidelines were from 24 countries distributed by geographic region: Europe: 13 (22,23,30–45), Asia: 4 (46–49), Africa: 4 (50–53), North America: 2 (54,55), South America: 2 (56,57), and Oceania: 1 (58). Most guidelines (n = 25) were written by a multiprofessional group of experts (≥3 medical or medicosurgical specialties involved). Infectious diseases specialists were systematically involved except for 2 guidelines from urologists (33,49). GPs were involved in the writing of 17 of the 36 included guidelines. Seven of the 29 updated guidelines were published between 2000 and 2010 and 22 after 2010. The characteristics of included guidelines are described in Table 6. Only one guideline evaluated infections in men only (49). The definition of mUTIs was not specified in 7 guidelines (31,32,41,48,50,51,59). Antibiotic therapy was not mentioned in 2 guidelines (41,57). The guidelines were not specifically written by GPs. However, 20 of the 36 included guidelines also discussed hospital management.

Quality assessment: AGREE II score

All updated guidelines were appraised using AGREE criteria (Table 3). Guidelines had good descriptions of their scopes and purposes (median 92%, IQR: [81–100]) and good scores in terms of clarity of presentation (86%: [67–94]). The rigor of development was extremely variable (IQR: [24–86]) with often a lack of clarity in the evidence selection process and the systematic method used. Three of 6 domains (stakeholder involvement, applicability, and editorial independence) obtained a median global score below 60%. Applicability was poor because potential impacts were not considered (29%: [17–63]). Seventeen guidelines also scored poorly on editorial independence due to a lack of clarity regarding funding relationships and the absence of an advisory opinion outside the working group. Finally, 14 guidelines obtained a total score of ≥60% for methodological quality (Supplementary Material).

LoE and SoR

Male UTI guidelines did not systematically use a grading system methodology. Only 18 updated guidelines used LoE (Tables 4 and 5). Guidelines without LoE systematically obtained a low score for methodological quality. AGREE II scores for quality of LoE were variable, 8 of 29 guidelines obtained a LoE score of <60% across all items (benefits and risks, strengths and limitations of evidence, and link between recommendations and SoR).

However, overall guidelines obtained a low SoR score because at best a moderate LoE was observed for FQ treatment trials (GRADE B) and mostly a low LoE with many expert opinions (GRADE C).

Nosology and symptoms

Eight different categories of mUTIs were described: “cystitis,” “complicated cystitis,” “pyelonephritis,” “prostatitis,” “symptomatic UTIs,” “complicated UTIs,” “male UTIs,” and “lower UTIs.” The terms “prostatitis” (n = 17), “cystitis” (n = 13), and “pyelonephritis” (n = 15) were the most used (Table 6).

Anatomic classification

The symptoms of “cystitis” included functional urinary signs (pollakiuria, burning micturition, hematuria, dysuria, urgency) without acute retention of urine, hypogastric pain, but no general signs (fever, aches, nausea, vomiting) or lumbar pain. Cystitis was sometimes defined as “complicated,” sometimes “at risk of complication,” or reserved for young men (not defined). One guideline mentioned the existence of “febrile cystitis” (38).

The symptoms of “pyelonephritis” included functional urinary signs without acute retention of urine, hypogastric pain and/or back pain, and/or general signs (fever, vomiting, nausea, aches). General signs might predominate without the presence of functional urinary signs.

The symptoms of “prostatitis” included functional urinary signs with possible acute retention of urine, hematospermia, retrograde ejaculation, perineal and hypogastric pain, and/or general signs (fever, vomiting, nausea, aches and pains) without associated back pain.

The “lower UTIs” seemed to be like cystitis with the same symptoms. To illustrate the difficulty of comparing the different nosology: the definition of “lower UTIs” is different between English and Korean guidelines: the former is closer to cystitis and the latter to prostatitis.

Symptomatic classification

This nosology is proposed by the French-speaking countries (22,60). The general term “mUTI” was defined as “any symptomatic community-acquired UTI in men, regardless of its location and severity, that has been evolving for less than 3 months” (22). This definition focused on symptom intensity and is divided in 2 categories: “Pauci-symptomatic mUTIs,” a synonym of cystitis, and “Symptomatic mUTIs,” which require immediate antimicrobial management when at least one of the following criteria is present (22):

• The presence of risk factors for complications (any anomaly of the urinary tree, severe immunodepression, severe chronic renal failure, age >75 years, or age > 65 years in the presence of fragility criteria) and regardless of symptoms.

• Significant fever or pain, or signs of mechanical complications such as acute urine retention.

Another symptomatic classification was proposed: “complicated UTI or at risk of becoming so.” It included symptoms of “cystitis” and “pyelonephritis.” It was defined as complicated by male anatomy. Prostatitis was considered a differential diagnosis (60).

Additional examinations

Urine dipstick

The value of the urine dipstick was usually mentioned but was not considered as sufficient to establish a diagnosis. In the Dutch GP and French guidelines, a positive nitrite urine dipstick in a suspected mUTI confirmed the diagnosis but a confirmation by cytobacteriological examination of urine (CBEU) was required (22,39).

Cytobacteriological examination of urine

CBEU was the gold standard for confirming the diagnosis of male UTIs. A large majority of guidelines considered leukocyturia to be significant when the threshold was >10³/mL or >10/mm³. Dutch GP guidelines proposed a higher threshold of >10⁴/mL (39).

The significant level of bacteriuria varied from 10³ colony forming unit (CFU)/mL (22,34,41,42,56,59), 10⁴ CFU/mL (31,33,36,39,55) to 10⁵ CFU/mL (46,47,50,55,57) and could depend on the germs found.

Prostate-specific antigen

No updated guidelines recommended a blood prostate-specific antigen test for the diagnosis of mUTIs. A negative result did not rule out a prostate infection and a positive result could help distinguish prostatitis, hyperplasia, or underlying cancer (22).

Imaging

Imaging was used to look for si of complications, particularly abscess formation: ultrasound urinary tract (22,36,47,56,57), computed tomography (47,54,56,57), and magnetic resonance imaging (54,57). Transrectal ultrasound was unreliable and could not be used as a diagnostic tool in prostatitis (33).

Antimicrobial treatment

FQ and sulfamides were the 2 most recommended classes of antibiotics in guidelines. FQ were systematically recommended if prostatitis involvement or fever are observed. Three guidelines did not specify the type of FQ recommended (48,59,61). FQ were the first choice in cystitis (43%), prostatitis (75%), and pyelonephritis (79%).

Cotrimoxazole was the first choice in cystitis (38%), prostatitis (25%), and pyelonephritis (28%). Diaminopyrimidines, exclusively represented by trimethoprim, were quoted in 9 guidelines, mainly from the UK and the Scandinavian countries and for the treatment of afebrile UTIs. UK guidelines recommended cotrimoxazole for prostatitis management and Swedish guidelines for pyelonephritis management.

Penicillins (co-amoxiclav, pivmecillinam, and amoxicillin) were recommended in 18 guidelines. Pivmecillinam was quoted in Scandinavian guidelines and recommended for the management of mUTIs without prostate or renal involvement. Fosfomycin was only recommended in the management of cystitis, either in single dose (guidelines from Argentina and Finland) or in 3 doses every 48 h (guidelines from the United States). Nitrofurantoin was recommended in guidelines from Northern European countries, the United States, Tonga, and Argentina, mainly for lower UTIs. Nitrofurantoin was not recommended when prostate involvement was suspected because it is unlikely to reach therapeutic levels in the prostate (UK guidelines).

Duration of antibiotic therapy

Limited to the analysis of the included guidelines, the duration of antibiotic therapy has decreased from 4 to 2 weeks for the treatment of acute bacterial prostatitis over the past 2 decades (61–63).

Treatment duration was short for cystitis or afebrile mUTIs, not exceeding 7 days with fosfomycin, nitrofurantoin, trimethoprim, cotrimoxazole (guidelines from Scandinavian countries, Argentina, the United States), and FQ (guidelines from the UK, Tanzania and Zimbabwe) (Figure 2).

Treatment duration varied from 5 to 14 days for pyelonephritis. The shortest treatment duration concerned FQ (5–7 days). Several guidelines suggested their use for longer periods, not exceeding 2 weeks (36,42,43,60). Cephalosporins, cotrimoxazole, and penicillins were mostly prescribed for 10–14 days. Trimethoprim (guidelines from Denmark) was prescribed for 14 days (Figure 2).

Treatment duration ranged from 10 to 14 days for acute prostatitis depending on the severity of the symptoms.

However, longer durations persisted in several guidelines: 14–21 days (43) and 4–6 weeks (34,61). A duration of more than 3 weeks was justified by the risk of chronic bacterial prostatitis and prostatic abscess. Trimethoprim was proposed as an alternative to FQ (if resistant) for 14 days. When betalactams were recommended, treatment times were longer than for FQ (Figure 2).

Sexually transmitted infections

A major diagnostic challenge was the confusion between mUTIs and sexually transmitted infections (STIs). Several guidelines (38,43,51,52,54,56) included the possibility of sexually transmitted prostatitis (involving Chlamydia trachomatis or Neisseiria gonorrheae), but this definition remains unclear.

Doxycycline was recommended when an STI was suspected and macrolides when the germ found in the antibiogram appeared atypical. In guidelines from Norway and Argentina, the treatment of chronic bacterial prostatitis also STI pathogens.

In guidelines from South Africa, men under the age of 35 with acute bacterial prostatitis were treated with doxycycline. The reason for this difference was not explained. In guidelines from Switzerland, STI screening was recommended for sexually active men.

Discussion

A lack of consensus on the definition of UTIs in adult men

The current guidelines are extremely heterogeneous for their quality, classification, and treatment of mUTIs. An international consensus on the management of UTIs in women exists but is lacking in men (64).

Classifications are diverse: we identified up to 5 synonymous definitions of cystitis: “UTIs at risk of complication,” “complicated UTIs,” “pauci symptomatic male UTIs,” “complicated cystitis,” and “lower urinary tract infection.” Some guidelines do not classify infections according to the organ and choose to distinguish either by severity (mainly fever) or by a high or low location (ill defined). Two categories can be distinguished: “afebrile mUTIs” and “febrile mUTIs.” “Afebrile mUTIs” correspond to infections of the lower urinary tract that involve neither the prostate nor the kidney and therefore have a low risk of complications (abscess, urosepsis, etc.). “Febrile mUTIs” include prostatitis and pyelonephritis. Pyelonephritis, when present, is defined and managed as the equivalent of female pyelonephritis and its treatment does not differ from that of women. The risk of complication of prostatitis is significant, and its treatment must be effective with good prostatic dissemination. The choice of the classification used modifies the therapeutic strategy. The guidelines defining cystitis recommend using antibiotics with poor prostatic penetration (i.e. nitrofurantoin) and a short duration of less than 7 days, while others suggest a treatment of at least 10 days.

Cystitis: a complicated diagnosis

Confirmation of bacteriuria by CBEU is necessary to define a mUTI. The Dutch College of General Practitioners (NHG) and the French Infectiology Society (SPILF) state that a positive nitrite dipstick test suggests a positive diagnosis of mUTI. However, CBEU is still essential because mUTIs are classified as complicated. Treating cystitis in men for less than one week is debated. Randomized controlled interventional trials of uncomplicated male UTIs are rare (3 trials) in primary care (18). Retrospective database studies in Scandinavia and the United States suggest the safety of a short duration of treatment for nonsevere infections (65–68).

Guidelines: a common objective, different messages

These nosological and therapeutic variations are categorized in 3 groups of guidelines with distinct messages and objectives: North European countries; African countries; French-speaking countries.

1. Guidelines from Scandinavian countries (Norway, Sweden, Finland, and Denmark), the United Kingdom, and the Netherlands proposed short courses of treatment (3–7 days), excluded FQ and recommended pivmecillinam, nitrofurantoin, or trimethoprim. These treatments are not recommended when prostate involvement is suspected. The duration and types of treatment are modulated according to the affected organ. These guidelines are based on expert opinion and noninterventional trials. However, several observational studies suggest that the risk of failure when treating an afebrile mUTI is low (65–68).

2. Guidelines from African countries and one from GPs in the United States suggest that young men with afebrile symptoms or at high risk of STIs should be treated for chlamydia and gonorrhea. The high incidence of STIs and the high proportion of young people in African countries could explain the focus of treatment on STIs, but their management is not detailed.

3. Guidelines from French-speaking countries recommend a watchful waiting approach. French-speaking countries (France, Quebec) suggest treating mUTIs regardless of fever, in the absence of complications. A watchful waiting approach is aimed at reducing FQ or cotrimoxazole consumption. An irritative syndrome, especially in men aged over 50, is not pathognomonic of an infection. The use of CBEU allows to discriminate lower urinary tract symptoms from cystitis (69). However, the treatment remains the same regardless of the severity of the symptoms: 14 days of FQ or cotrimoxazole.

All FQ or other alternatives?

Burden of FQ resistance?

The duration of FQ treatment for prostatitis has been gradually reduced over the last 20 years from 28 to 10–14 days. FQ remains the most widely used antibiotic for the treatment of male UTIs. In 2019, 1.27 million deaths were attributable to bacterial antimicrobial resistance (AMR), while FQ-resistant (FQ-R) E. coli caused 50,000–100,000 deaths (13). In 2020, the European Center for Disease Prevention and Control (ECDC) reported a FQ-R E. coli of 25% or more in 20 (50%) countries (11). Between 2011 and 2020, there were statistically significant decreases in the EU/EEA mean consumption of quinolones (70). To reduce FQ consumption, guidelines from North European countries recommend treating cystitis with pivmecillinam, trimethoprim, or nitrofurantoin.

Availability of “forgotten” antibiotics?

WHO-Essential List of Medicines (EML) include “access” antibiotics, considered essential to treat common infection (14,15). The European Society of Clinical Microbiology and Infectious Diseases Study Group for Antimicrobial Stewardship (ESGAP) examined the availability of so-called “forgotten” antibiotics in high-income countries (HICs) and low- and middle-income countries (HICs and LMICs) (71,72). Fosfomycin, pivmecillinam, trimethoprim, and nitrofurantoin are on the list of “forgotten” antibiotics. Only nitrofurantoin is on the WHO-EML. Their availability in HICs is improving, for example trimethoprim in France (73). In LMICs, the availability of “forgotten” antibiotics is inconsistent: nitrofurantoin is available in two-thirds of LMICs, fosfomycin in one half, and pivmecillinam is unavailable (72).

What guidelines for primary care?

Unpublished guidelines

The included updated guidelines are not published in the literature. UTI guidelines concern several specialties: GP, urology, infectious diseases, etc. Guidelines are often based on evidence of uncertain relevance for primary care patients (74). The definition and the management of cystitis in men are based on experts’ opinions because clinicals trials are rare in primary care.

A low level of evidence and low strength of recommendations

Guidelines were mainly based on expert opinions (GRADE C); only guidelines on the efficacy of FQs in prostatitis have a moderate LoE (GRADE B). Clinical trials in primary care on antimicrobials in male UTIs are recent and not yet included in guidelines (19–21). We often find the same references cited, sometimes outdated and not adapted in primary care: interventional trials in chronic prostatitis (75–78) or expert opinion (79,80). The low rate of broad-spectrum antibiotic consumption in Northern EU/EEA countries explains their low rate of AMR events although their LoE in male UTIs is not proven (11).

Guidelines on male UTIs should systematically ensure that their authors used appropriate development and reporting frameworks, such as the AGREE II checklist. Only 8 guidelines explicitly stated that they used this framework (31,36,38,39,41,47,60,62). Guidelines on male UTIs with the lowest scores (<60%) are either integrated into very general guidelines on antibiotic use (such as guidelines from African countries) or do not use a LoE grading system. By adhering to these standards, guidelines can improve their quality and promote applicability and uptake.

Strengths and limitations

Limitations

This review attempts to be systematic but accessing guidelines for each country was difficult. The reasons are many: lack of publications, lack of translations in English, restricted access to guideline websites, and indexation errors in bibliographic databases.

A further difficulty is that guidelines for men are rarely isolated from guidelines for women, and it was necessary to broaden the search to include UTI guidelines for all patients at the time of registration of eligibility.

Strength

To our knowledge, this is the first systematic literature review of mUTI guidelines in primary care. The lack of consensus is known, but there is no visibility regarding the definition of mUTIs and their management. Although not exhaustive, our results seem to cover all continents worldwide. The evaluation of the guidelines using the AGREE II checklist allowed not only a descriptive evaluation but also a qualitative evaluation of their construction.

Conclusion

Guidelines are mainly based on expert opinion, but definitions and therapeutic proposals differ according to the prescribing practices of each country. The European Association of Urology and the Asian Association of Urinary Tract Infection and Sexually Transmitted Infection have published consensus guidelines for urology, but there are no equivalent guidelines for infectious diseases or primary care. Differences in management are mostly significant within Europe with a North/South gradient regarding FQ prescribing. Understanding the burden of AMR is crucial to making informed and location-specific policy decisions, particularly about infectious diseases guidelines, and access to essential and “forgotten” antibiotics.

The objective “shorter is better” (81) is respected in several guidelines by recommending short treatments of less than 7 days and without FQ. However, LoE is low in the absence of an interventional trial. Given the low incidence of male UTIs in primary care, interventional trials are rare (19,21). Retrospective studies based on electronic medical records provide new perspectives (2,7,65–68). Qualitative studies with patients and practitioners could explore the different entities and practice experiences (8,82). The diversity and multiplication of research methodology in primary care will probably strengthen the LoE on treatment of male cystitis and improve antibiotic stewardship.

Acknowledgements

The authors are grateful to Prof. Manuel Etienne for his expertise and insights on male urinary tract infections and to Nikki Sabourin-Gibbs, CHU Rouen, for her help in editing the manuscript.

Funding

None declared.

Conflict of interest

The authors declare that they have no conflict of interest in relation to the content of this article. Author’s declaration of interest is publicly available on www.transparence.sante.gouv.fr and www.archimede.fr/DpiRecherche.

Ethics

No necessary ethical approval(s).

Data Availability

This study does not require agreement from the National Commission for Informatics and Liberties.

References